Drug documentation and drug history taking

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Drug documentation and drug history taking
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Allergies

• Are you allergic to any drugs?
• What happened when you took this medication?
• When was this reaction?
• Have you taken that medication since?
• Do you have any other allergies?

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Drug history

• Are you taking any tablets or use any inhalers at
  the moment?
• What do you take that for?
• How many times a day do you take your medication?
• How many do you take?
• Do you know the strength of the tablets?
• Do you buy medication from the chemist?
• Do you take any other drugs( herbal or
  recreational!)

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• 35 year old obese woman.
• PMH asthma.
• In bed for past few days with fever.
• Diagnosed with a chest infection and DVT.
• Her regular medication includes ventolin when she
  wants Becotide 50 mcg 2 puffs twice a day.
• She takes the oral contraceptive pill
  microgynon-30.
• Solpadol 2 tabs every 6 hours for back pain.
• She is allergic to penicillin.
• The registrar asks you to write up a loading dose
  of wafarin 6mg.
• Microbiology recommends Erythromycin 500mg TDS
  for her chest infection.
• The nursing staff ask you to prescribe lactulose,
  paracetamol and night sedation.

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